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' A ►�' SAN JCACUIN C PU8LIC HEALTH SERVICES - ENVIRCNMENTAL HEALTH DIVSICN <br /> UOUND STORAGE TANK PROGRAM - FEE UCRKSNEET <br /> FACILITY SITE .NAME FACILITY CON CT NAME <br /> S <br /> I I 6ZO I K STo to M�42•K� #(21 &W F-JA-T•K 51 AJ& ( <br /> E' FACILITY ADDRESSSI E PHC E 4 with AREA CODE <br /> &I l )q(o W6-ST (,ocJcSIF WJE 7-("1 231 - 2,15-7 <br /> AI CITY MiN`r IEGf�c I STITEI ZS <br /> jE�/ of TANKS <br /> S _✓ (o at SITE <br /> PI APPLICANT/BILLING NAME APPLICANT CONTACT NA; <br /> L! 6.0 1 K 5 Toe ILIA�K�ZS !NL• I /M I KE Lee <br /> �1NC�t� <br /> CI MAILING ADORES APPLI NT PH NE I WITH AREA CCOE <br /> A po. BoX 5� 45' I Rl� 73 -ll(8 <br /> N - <br /> TYPE of <br /> PLICATION <br /> T CITY STATE ZIP CODE (CLosure,PinstaLLation, etc.) <br /> GA- `i453�- I <br /> TOTAL <br /> 1986 11987 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> Al XXXX XXXX XXXX XXXX I XXXX 5 XXXXXXXX <br /> C <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX I XXXX I XXXX S XXXXXXXX <br /> I, <br /> Vi TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E Tanks = 1986 1987 ( 1988 11989 11990 1991 11992 1993 11994 ! 1995 1998 <br /> F, (multiply R by fee for <br /> Al each year applicable) XXXX XXXX XXXX I XXXX XXXX XXXX I I S <br /> It TANK PENALTY FEES ASSESSED I XXXX XXXX f XXXX I XXXX XXXX I XXXX ! I I 5 <br /> I I STATE SURCHARGE _ TAPJK- K $S,OO <br /> T <br /> Yl tg•5 FOL FAuLAT <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 4(s) <br /> OI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) TANK(s)—_ X 5234.00 = 3 <br /> S' <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. »(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 ;minimum 5 <br /> Pi INSTALLATICN PLAN CHECK (Plan Review & Construction Inspections) TANK L.D. 4(s) <br /> L <br /> A <br /> l010 <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> Rl REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) X S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY 00 <br /> ........................................«_............ <br /> ...........:��:::::::::._..:�..�.�.._......._....__.._.._._. Y:::......-......_...__:::::::::.»..��::..�.��:�::.^..��.«._..._..`..».».�_.«_�_�......«...-.»..._..._.._..._.�.'r'..._..-._ <br /> :::::::::::::::5.:'�.��'�:::�.•�i—.:�'::::�:.::::::Y..••.•E.�::•�fs.�:��::.•.M.•:��_::::::r����..»__....��_..�-«__��«t•:::.�«.:�.�.!':�:::::».w•.�..�•Y•�^:].�:�:::::�::::::::�.�»...:�:e.•R•�«":x::::::�:^��.::::.••:-�::�:.:::::i.»:^.:�':::—...:..�::C::i•.::..::LGTif�«a <br /> SWEEPS I COMPUTER 4 LCC CODE DIST CODE AMOUNT RECEIVED I CHECK X/CASH ( RECEIVED BY I DATE RECEIVED - <br /> ...........___.... «--�_3 <br /> _.«.._..............._..................._.......... - ....__...__._......__........__.........«..._..«...«_.._..�_._.._._....._.._ ._ ._.... ._.........___... ....r._............_.._.._.........__.___...^— <br /> ........«.............._..........»_......................-...._.».......�_ .».........._.........._.............._...._....... _.._...._._.�_._.......:»•.^•- ..........._.....::::::::.^:..._.....-..___..._........._..........«......_....».».x•:ii=:•:e= :r.:::� n <br /> TCT/WE (REVISEDI'-11-97) <br />